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1 Protocol for Excessive Grief Marilyn Luber Philadelphia, PA Protocol for Excessive Grief is excerpted from Eye Movement Desensitization and Reprocessing (EMDR) Scripted Protocols: Basics and Special Situations illustrating a scripted protocol from one of Francine Shapiro s 6 basic protocols. Scripting informs and reminds EMDR practitioners of the component parts, sequence, and language used to create effective outcomes, and also generates a template for practitioners and researchers to use for reliability and/or a common denominator so that the form of working with EMDR is consistent. This protocol includes 5 steps: process actual events, including the loved one s suffering or death; process any intrusive images that are occurring; process the nightmare images; process any stimuli/triggers associated with the grief experience; and address issues of personal responsibility, mortality, or previous unresolved losses. The future template is included This protocol addresses the many aspects of grief and mourning to assure the full processing of clients concerns. Keywords: EMDR scripted protocols; EMDR; grief; death; intrusive images; unresolved loss Scripted protocols were developed so that eye movement desensitization and reprocessing (EMDR) practitioners could access EMDR protocols in a way that adheres to best EMDR clinical practices (Luber, 2009a, 2009b, 2012a, 2012b). This means incorporating the Standard EMDR Protocol that comprises working on the past, present, and future issues (the 3-Pronged Protocol) related to the problem and the 11-Step Standard Procedure that includes attention to the following steps: image, negative cognition (NC), positive cognition (PC), validity of cognition (VoC), emotion, subjective units of disturbance (SUD), and location of body sensation, desensitization, installation, body scan, and closure. Often, EMDR texts embed the protocols in a great deal of explanatory material that is essential in the process of learning EMDR. However, sometimes, as a result, practitioners move away from the basic importance of maintaining the integrity of the Standard EMDR Protocol and keeping adaptive information processing in mind when conceptualizing the course of treatment for clients. It is in this way that the efficacy of this powerful methodology is lost. Scripting becomes a way not only to inform and remind the EMDR practitioner of the component parts, sequence, and language used to create an effective outcome, but it also generates a template for practitioners and researchers to use for reliability and/or a common denominator so that the form of working with EMDR is consistent. However, it is important to remember that reading a script is by no means a substitute for adequate training, competence, clinical acumen, and integrity; if you are not a trained EMDR therapist and/or you are not knowledgeable in the field for which you wish to use the script, this script is not for you. The Protocol for Excessive Grief (Luber, 2009a, pp ) is based on Dr. Shapiro s (2001) text and article (Shapiro, 2006). When someone we love dies, there is a process of grief and mourning that occurs naturally and resolves over time. However, when the level of suffering and self-recrimination is so intense that adjustment to the loss is impaired, EMDR offers a way to mourn in a more balanced manner yet does not preclude the normal, appropriate emotions such as sadness and grief. In this protocol, it is often helpful Editor s Note: This article is a reprint from Eye Movement Desensitization and Reprocessing (EMDR) Scripted Protocols: Basics and Special Situations, (pp ), by M Luber, 2009, New York, NY: Springer Publishing. Copyright 2009 by Springer Publishing. Reprinted with permission. Journal of EMDR Practice and Research, Volume 6, Number 3, EMDR International Association
2 to target any of the past intrusive memories, nightmares, or fantasies related to the loved one that may be blocking clients access to the full scope of their relationship that includes the happy and positive experiences they had together. Addressing present triggers such as any situations, events, or stimuli that trigger clients grief is essential for a full understanding and processing of clients experiences. Issues of personal responsibility and safety may arise as the intense grief is processed and are an important part of treating the hidden part of the suffering. Other targets may include earlier unresolved losses and clients thoughts about personal injury and/or mortality of other loved ones. The ultimate goal is that clients are able to accept the loss of the loved one and have access to the wide range of feelings and experiences that they shared together and move forward in their own lives. Excessive Grief Script Notes This protocol (Luber 2009a, pp ) is to be used when there is a high level of suffering, self-denigration, and lack of remediation over time concerning the loss of a loved one. EMDR does not eliminate healthy appropriate emotions, including grief. It allows clients to mourn with a greater sense of inner peace. The protocol is similar to the Standard EMDR Protocol for trauma. The goal of this work is to have your client accept the loss and think back on aspects of life with the loved one with a wide range of feelings, including an appreciation for the positive experiences they shared. Francine Shapiro often brings up the issue: How long does one have to grieve? She asks us to not place our limitations on our clients as this would be antithetical to the notion of the ecological validity of the client s self-healing process. For example, a woman who believed that the death of her infant son was her fault despite her doing everything she could to prevent it, worked with EMDR soon after his death. I can feel him in my heart. I am grateful for the time we had together. He s in a better place Her work with EMDR did not take away her grieving but allowed her to accept the loss and to have a full range of feelings about her son. The following is a summary of the Excessive Grief Protocol (Shapiro, 2001, p. 232). When there is excessive grief, target the following: Past Memories 1. Actual events, including the loved one s suffering or death 2. Intrusive images 3. Nightmare images Present Triggers 4. Present triggers 5. Issues of personal responsibility, mortality, or previous unresolved losses Future Template 6. Create a future template Excessive Grief Protocol Script Past Memories Step 1: Process Actual Events, Including the Loved One s Suffering or Death Say, What are the moments or events that stand out concerning your loved one s death? Reprocess the event using the Standard EMDR Protocol. Say, The memory that we will start with today is (state the target of the loved one s suffering or death). Say, What happens when you think of (state the target of the loved one s suffering or death)? Or say, When you think of (state the target of the loved one s suffering or death), what do you get? Say, What picture represents the entire (state the target of the loved one s suffering or death)? of the (state the target of the loved one s suffering or death)? Say, What words best go with the picture that express 130 Journal of EMDR Practice and Research, Volume 6, Number 3, 2012 Luber
3 Positive Cognition (PC) Say, When you bring up that picture or (state the target of the loved one s suffering or death), what would you like to believe about yourself now? Say, When you think of the (state the target of the loved one s suffering or death, or picture), how true do those words (clinician repeats the positive cognition) feel to you now on a scale of 1 to 7, where 1 feels completely false and 7 feels completely true? Say, Remember, sometimes we know something with our head, but it feels differently in our gut. In this case, what is the gut-level feeling of the truth of (clinician states the positive cognition), from 1 (completely false) to 7? Emotions Say, When you bring up the picture (state the target of the loved one s suffering or death) and those words (clinician states the negative cognition), what emotion do you feel now? Say, On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does it feel now? (no disturbance) (highest disturbance) Continue with Phases 4 through 7 for each incident. Step 2: Process Any Intrusive Images That Are Occurring Say, Are there any intrusive images that you are experiencing? Reprocess any intrusive images using the EMDR Standard Protocol. Say, The intrusive image that we will start with today is (select the intrusive incident to be targeted). Say, What happens when you think of the intrusive image? Or say, When you think of the intrusive image, what do you get? Say, What picture represents the entire intrusive image? of the intrusive image? Say, What words best go with the picture that express Positive Cognition (PC) Say, When you bring up that picture or intrusive image, what would you like to believe about yourself now? Say, When you think of the intrusive image (or picture), how true do those words (clinician repeats the positive cognition) feel to you now on a scale of 1 to 7, where 1 feels completely false and 7 feels completely true? Say, Remember, sometimes we know something with our head, but it feels differently in our gut. In this case, what is the gut-level feeling of the truth of (clinician states the positive cognition), from 1 (completely false) to 7? Journal of EMDR Practice and Research, Volume 6, Number 3, Protocol for Excessive Grief
4 Emotions Say, When you bring up the picture (or intrusive image) and those words (clinician states the negative cognition), what emotion do you feel now? Say, On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does it feel now? (no disturbance) (highest disturbance) Continue with Phases 4 through 7 for each incident. Process all of the intrusive images, checking after the completion of each one to see if other targets need to be processed. If so, continue the processing until all are completed and then move on to the next step. Step 3: Process the Nightmare Images Say, Are you having any nightmares concerning your loved one? What are the images that are coming up from your nightmares? Process the nightmares concerning the loved one with the Standard EMDR Protocol. Say, The nightmare that we will start with today is (select the nightmare to be targeted). Say, What happens when you think of the nightmare? Or say, When you think of the nightmare, what do you get? Say, What picture represents the entire nightmare? of the nightmare? Say, What words best go with the nightmare that express Positive Cognition (PC) Say, When you bring up that picture or nightmare, what would you like to believe about yourself now? Say, When you think of the nightmare (or picture), how true do those words (clinician repeats the positive cognition) feel to you now on a scale of 1 to 7, where 1 feels completely false and 7 feels completely true? Say, Remember, sometimes we know something with our head, but it feels differently in our gut. In this case, what is the gut-level feeling of the truth of (clinician states the positive cognition), from 1 to 7 (completely true)? Emotions Say, When you bring up the picture (nightmare) and those words (clinician states the negative cognition), what emotion do you feel now? Say, On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does it feel now? (no disturbance) (highest disturbance) 132 Journal of EMDR Practice and Research, Volume 6, Number 3, 2012 Luber
5 Continue with Phases 4 through 7 for each incident. Process all of the nightmares, checking after the completion of each one to see if other targets need to be processed. If so, continue the processing until all are completed and then move on to the next step. Present Triggers Step 4: Process Any Stimuli or Triggers Associated with the Grief Experience Say, What situations, events, or stimuli trigger your grief? Let s process these situations, events, or stimuli triggers one by one. Situations, Events, or Stimuli of Grief Trigger List Say, The situation, event, or stimulus that triggers you that we will start with today is (select the next trigger to be targeted). Say, What happens when you think of the (state the situation, event, or stimulus) that triggers you? Say, When you think of the (state the situation, event, or stimulus) that triggers you (or picture), how true do those words (clinician repeats the positive cognition) feel to you now on a scale of 1 to 7, where 1 feels completely false and 7 feels completely true? Say, Remember, sometimes we know something with our head, but it feels differently in our gut. In this case, what is the gut-level feeling of the truth of (clinician states the positive cognition), from 1 (completely false) to 7? Emotions Say, When you bring up the picture or (state the situation, event, or stimulus) that triggers you and those words (clinician states the negative cognition), what emotion do you feel now? Or say, When you think of (state the situation, event, or stimulus) that triggers you, what do you get? Say, What picture represents the entire (state the situation, event, or stimulus) that triggers you? of the (state the situation, event, or stimulus) that triggers you? Say, What words best go with the picture that express Positive Cognition (PC) Say, When you bring up that picture or (state the situation, event, or stimulus) that triggers you, what would you like to believe about yourself now? Say, On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does it feel now? (no disturbance) (highest disturbance) Continue with Phases 4 through 7 for each incident. Process all of the present triggers, checking after the completion of each one to see if other targets need to be processed. If so, continue the processing until all are completed and then move on to the next step. Step 5: Address Issues of Personal Responsibility, Mortality, or Previous Unresolved Losses Personal responsibility and safety issues may arise after the intense sadness and emotional pain are processed. Jot them down as your client is processing them and make sure to be respectful as he reveals this hidden part of his suffering. Look for earlier Journal of EMDR Practice and Research, Volume 6, Number 3, Protocol for Excessive Grief
6 experiences of unresolved emotional loss(es). Make sure to question the client s thoughts about personal injury or the mortality of other family members. Using the Float-Back Technique and/or the Affect Scan can be helpful here. Say, Are there any other issues where you felt responsible for saying or doing something negative or unkind to your loved one? Say, Are there any other issues that you have concerning your personal safety or the personal safety of others? Say, Are there earlier losses that have come up since the loss of your loved one? Say, Are you concerned about anything happening to other family members or friends in your life since your loss or before? Reprocess these issues using the Standard EMDR Protocol. Say, The issue that we will start with today is (select the next issue to be targeted). Say, What happens when you think of (state the issue)? Or say, When you think of (state the issue), what do you get? Say, What picture represents the entire (state the issue)? of (state the issue)? Say, What words best go with the picture that express Positive Cognition (PC) Say, When you bring up that picture or (state the issue), what would you like to believe about yourself, now? Say, When you think of the (state the issue, or picture), how true do those words (clinician repeats the positive cognition) feel to you now on a scale of 1 to 7, where 1 feels completely false and 7 feels completely true? Say, Remember, sometimes we know something with our head, but it feels differently in our gut. In this case, what is the gut-level feeling of the truth of (clinician states the positive cognition), from 1 (completely false) to 7? Emotions Say, When you bring up the picture (state the issue), and those words (clinician states the negative cognition), what emotion do you feel now? Say, On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does it feel now? (no disturbance) (highest disturbance) 134 Journal of EMDR Practice and Research, Volume 6, Number 3, 2012 Luber
7 Process all of the relevant issues concerning personal responsibility, mortality, or previous unresolved losses, checking after the completion of each one to see if other targets need to be processed. If so, continue the processing until all are completed. Again, remember that the goal of this work is to have your client accept the loss and think back on aspects of life with the loved one with a wide range of feelings, including an appreciation for the positive experiences they shared and how to hold those positive feelings and move forward into the future. Create a Future Template Note that in the summary for the Protocol for Excessive Grief (Shapiro, 2001, p. 225), Dr. Shapiro does not mention the use of any future templates, however, the use of the future template is implicit in all EMDR work. See Appendix A in Luber (2009a). EMDR Summary Sheet In Luber (2012), summary sheets are included with the scripted protocols. The goal of the summary sheet is to allow for the recording of the data collected in the scripted protocol and to serve as a memory tickler for the protocol itself. It is found in Eye Movement Desensitization and Reprocessing (EMDR) Scripted Protocols with Summary Sheets CD-ROM Version: Basics and Special Situations (Luber, 2012). The summary sheet in this CD and downloadable version allows for an expandable, downloadable format that can be digitally accessed. Because EMDR is a fairly complicated process, and often intimidating, this scripted protocol with its summary sheet can be helpful in several ways. To begin with, by facilitating the gathering of important data from the protocol about the client, the scripted protocol and/or summary sheet then can be inserted into the client s chart as documentation. The summary sheet can assist the clinician in formulating a concise and clear treatment plan with clients and can be used to support quick retrieval of the essential issues and experiences during the course of treatment. Practitioners can enhance their expertise more quickly by having a place that instructs and reminds them of the essential parts of EMDR practice. By having a fill-in portable document format (PDF) form, clinicians can easily tailor the scripted protocol and summary sheet to the needs of their clients, their consultees, and themselves by editing and saving the protocol script and summary sheet. The script and summary sheet forms are available as a digital download or on a CD-ROM, and work with any computer or device that supports a PDF format. References Luber, M. (Ed.). (2009a). Eye movement desensitization and reprocessing (EMDR) scripted protocols: Basics and special situations. New York, NY: Springer Publishing. Luber, M. (Ed.). (2009b). Eye movement desensitization and reprocessing (EMDR) scripted protocols: Special populations. New York, NY: Springer Publishing. Luber, M. (Ed.). (2012a). Eye movement desensitization and reprocessing (EMDR) scripted protocols with summary sheets CD-ROM version: Basics and special situations. New York, NY: Springer Publishing. Luber, M. (Ed.). (2012b). Eye movement desensitization and reprocessing (EMDR) scripted protocols with summary sheets CD-ROM version: Special populations. New York, NY: Springer Publishing. Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd ed.). New York, NY: Guilford Press. Shapiro, F. (2006). EMDR: New notes on adaptive information processing with case formulation principles, forms, scripts and worksheets. Watsonville, CA: EMDR Institute. Correspondence regarding this article should be directed to Marilyn Luber, PhD, Medical Tower Building, 255 S. 17th Street, Suite 804, Philadelphia, PA marluber@aol.com Journal of EMDR Practice and Research, Volume 6, Number 3, Protocol for Excessive Grief
8 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
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